Observations, Ruminations, and Cantankerous Notions

Quarantine

Checking the news I happened to come across this item: Kaci Hickox is suing New Jersey Governor Chris Christie. If the name Kaci Hickox doesn’t ring a bell, she’s the nurse who helped treat Ebola victims, was quarantined on her arrival to the US, and broke it after a few days. It turned out that Ms Hickox did not have Ebola. Now, with the help of the ACLU, she’s suing.

When Ebola entered the country last year, the issue of quarantine had self-appointed civil libertarians all a flutter. Being old enough to remember when quarantines were a common medical practice, that was something of a head scratcher. Of course, I’m getting long in the tooth, and so these young whipper snappers likely haven’t a clue when it comes to quarantines, how it works, or its purpose. That quarantines are no longer common has much to do with vaccinations. Yet the speed we’ve forgotten them is amazing, considering that in the early 1960s quarantines were so familiar that it showed up as gag in an episode of The Flintstones.

The purpose of a quarantine is simple: To contain the spread of disease. Back before widespread vaccinations and effective medicines and treatment, this was the only way to stop most diseases. When a ship arrived from a country with an epidemic, or with sick crew or passengers, it was quarantined until it was shown to be disease free before it was allowed to dock. On land, the sick and anyone who came in contact with them were also quarantined.

Usually it was sufficient to declare quarantine, as most people realized its purpose. When it was not, mandatory quarantines were imposed by force. The most famous US example is Mary Mallon, known as Typhoid Mary, who was forcibly quarantined, first as a carrier of typhoid, and later because she continued to work as a cook. Suffice to say that quarantine, both of arrivals from countries where a disease was rampant, and of the infected and those who came in contact with them, is nothing new in US law. The balance between public good and civil liberties was hammered out long ago.

We see this in the case of Mary Mallone. Mary Mallone was an Irish immigrant who worked as a cook, and several cases of typhoid, some fatal, were traced to her. Confronted, Mary Mallone refused testing for typhoid, and at one point became violent. She was arrested, and in subsequent tests was found to be carrying typhoid in her gall bladder. She didn’t believe she was infected (or, for that matter, in hand washing), and refused to have her gall bladder removed. She remained in quarantine for three years, then released with the admonition to never work as a cook again. After another series of outbreaks, Mary Mallone was found, under an assumed name, to be working as a cook once more. She was arrested, and placed in quarantine for the rest of her life. The important thing to note is that at each point, government involvement was a last resort.

First Mary Mallone refused to allow a private researcher, who tracked the typhoid cases to her, to test her. After another outbreak, the New York Board of Health sent a doctor to request testing. When Mallone refused and became violent, the doctor returned the next day with police, who arrested her. Only then was she subject to forced testing. On discovering she was infected , she was given the option of treatment. Only after she refused was she kept in quarantine for three years, until she was released with the warning never to work as a cook again. Only after she made efforts to evade the law by changing her name and after other outbreaks were traced to her, she was quarantined for life.

I’ll leave it to the law students to hash out probable cause and find whether a warrant was obtained for testing. The important thing to note here is that Mallone was subject to limited curtailment of her civil rights. First, she was released from quarantine, as it was believed she posed little risk of spreading disease as long as she didn’t work as a cook. Second, it was only after she attempted to evade the law, and after more sickness and death, that she was finally quarantined for life. Third, and perhaps most important, the government did not force the removal of her gall bladder, even though it possibly would have cured her from being a carrier. It was sufficient, to protect the health of the public, to keep her in quarantine. Beyond that, the law went no further. Considering that three deaths were tied to her, some after she was warned to stop working as a cook, she could have faced the electric chair.

All of which is still pertinent a century later. While the idea of quarantining airline passengers from countries with Ebola epidemics brought howls of protest, such was the norm in the days of ocean liners. Fortunately, while deadly, Ebola victims do not become infectious until they display symptoms. This may have been in the back of Ms. Hickox’s mind when she broke quarantine. Fortunately, she wasn’t infected with Ebola. Yet, as in the case of another nurse who had a low grade fever when she contacted the CDC only to develop them while traveling, the problem is where an individual would be if they begin to show symptoms and would they notice it in time to prevent exposure to others.

Preventing the spread of disease is the entire purpose of quarantines. Even the first Apollo astronauts who landed on the moon were placed in quarantine, just in case. And unlike the slim hypothetical possibility of lunar disease, the threat from Ebola is very real, particular with those who come into contact with victims.

How Ms. Hickox’s lawsuit will go is anyone’s guess. It’s hopeful that a judge will toss it. The two who contracted Ebola in the US both treated the first Texas case, and infection of doctors and nurses who treat Ebola cases is disturbingly common. Yet the judge probably won’t; judges don’t seem to do that much anymore. The outcome will have a huge impact on the control of the spread of disease. If Ms. Hickox loses, quarantines will proceed as they have in the past, following legal precedents. If she wins, state and federal governments will be hesitant to employ a proven means of disease control, which means the possibility of illness spreading farther than it would otherwise.

Us older heads remember the reason for quarantines. I hope it’s a lesson we never have to relearn.